Free rib transfer by microvascular anastomoses.
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Biomedical subjects
Publications and source records attributed to R K Daniel.
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Although recent advances in clinical microsurgery have made free tissue transfer a clinical reality, the value of free bone transfers in the reconstructive tumor surgery of long bones has not been reported to our knowledge. Two patients with malignant or aggressive bone tumors who underwent en bloc resection of their tumors and reconstruction with free vascularized bone grafts are presented. In the first case, a giant cell tumor of the distal radius was resected, and a 10 cm free vascularized fibular graft was performed as a reconstructive procedure; in the second case a chondrosarcoma of the femur was excised and replaced by a 20 cm segment of free vascularized fibula. Postoperatively, these patients were followed with arteriograms and sequential bone scans. The indications for the procedure and the operative technique are discussed. A comparison of the merits of free rib versus free fibular transfers is presented with emphasis on bony architecture, vessel characteristics, dissection required and the options available for reconstructive surgery. The advantages and disadvantages of free vascularized bone grafts with respect to conventional methods and the potential applicability of this technique are discussed.
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Sensory skin flaps represent a possible solution for the paraplegic who has the problem of recurrent pressure sores. An intercostal neurovascular island flap has been used in 3 cases to provide coverage for sacral ulcers. Sensation was retained to a variable degree in both adults and children. An attempt at coverage of an ischial ulcer with an intercostal neurovascular free flap is also reported. The practical and theoretical aspects of these procedures are discussed.
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The reconstructive surgeon who wishes to learn microsurgery must realize that its acquisition demands extensive practice in the research laboratory with clinical application occurring after perfection of the fundamental techniques. Their initial usage should be in traumatic extremity injuries followed by replantation of complete and incomplete amputations. Elective reconstructive microsurgery demands consummate clinical skills and should not be attempted except by those who have convincingly demonstrated their microsurgical skills either in replantation surgery or in the research laboratory.
An experimental, anatomical, and clinical study has confirmed the feasibility of free neurovascular flaps. The interrelationship between the cutaneous vascular and neural supply has been defined and demonstrated electrophysiologically, both in man and in experimental animals. A potential donor site in man has been explored. Free neurovascular flap transfers by microneurovascular anastomoses are technically feasible. Clinical success will occur with the identification of suitable donor sites.
The vascular anatomy of the supplying vessels to the iliofemoral, the deltopectoral, the axillary, and the thoracoabdominal regions has been investigated in detail in fresh cadavers. Other donor sites were also examined. The anatomical relationship of the supplying vessels is discussed-and the design, conversion, and utilization of these skin areas as donor sites for free flap transfer are detailed. The iliofemoral region is suggested as the best donor site for most free flap procedures.
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An anatomical and hemodynamic study of the deltopectoral flap in cadaver dissections and clinical cases is described. Anatomically, the deltopectoral flap represents a fusion of 3 vascular regions supplied by 3 different sets of vessels. Hemodynamically, the flap consists of a lateral cutaneous flap nourished by a medial arterial pedicle. The method of choice for delay of a deltopectoral flap is discussed.
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